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What Combination Therapy with a Statin, If Any, Would You Recommend?

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Abstract

The latest recommended goals for blood lipid levels may require multiple lipid drugs. Lower doses in combination may render more efficacy and safety than highest doses of single agents. Except for isolated hypoalphalipoproteinemia (a low level of high-density lipoprotein cholesterol), therapies will start with a statin. All marketed statins are acceptable. The choice may be based on dose- efficacy and patient’s tolerability. High-potency statins (eg, atorvastatin, simvastatin, or rosuvastatin) are often chosen. Currently, generic statins, such as simvastatin, lovastatin, pravastatin, and fluvastatin, offer cost benefits. The choice of added agent depends on the “residual lipoprotein abnormalities” after statin therapy, efficacy, compliance issues, and cost. Approved “combined” preparations improve cost and compliance. To further lower low-density lipoprotein cholesterol, ezetimibe is a safe, efficacious choice, pending resolution of a controversial trial’s results. Colesevelam is moderately effective and the best tolerated bile acids sequestrant. In combined dyslipidemias, extended-release niacin is the best tolerated niacin preparation; other quality-controlled immediate-release preparations have similar safety and efficacy but produce more flushing of the skin. Niacin or fenofibrate is effective in normalizing high-density lipoprotein and triglyceride levels persisting after statin therapy. Agents approved by the US Food and Drug Administration and the latest guidelines of the National Cholesterol Education Program, American Heart Association/American College of Cardiology provide choices and indications of drug combinations.

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Disclosure

Carlos A. Dujovne reports no potential conflict of interest relevant to this article. Craig D. Williams has received honoraria from Merck & Co. Matthew K. Ito has been a consultant for Daiichi Sankyo and received speaker fees from Abbott Laboratories and Merck & Co.

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Authors and Affiliations

  1. Division of Cardiovascular Medicine, Oregon Health and Science University (OHSU), Portland, OR, 97239-3098, USA

    Carlos A. Dujovne

  2. Clinical Cardiovascular-Metabolic Risk Prevention &Treatment Programs, UHN-62 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239-3098, USA

    Carlos A. Dujovne

  3. OSU/OHSU School of Pharmacy, Portland, OR, 97239, USA

    Craig D. Williams

  4. OHSU School of Medicine, 3303 SW Bond Ave., CH12C, Portland, OR, 97239, USA

    Craig D. Williams

  5. Cardiovascular Pharmacodynamics Laboratory, Oregon State University/Oregon Health & Science University, Portland, OR, 97239, USA

    Matthew K. Ito

  6. College of Pharmacy, Portland Campus at OHSU, 3303 SW Bond Ave, Portland, OR, 97239, USA

    Matthew K. Ito

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  1. Carlos A. Dujovne
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  2. Craig D. Williams
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  3. Matthew K. Ito
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Correspondence to Carlos A. Dujovne.

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Dujovne, C.A., Williams, C.D. & Ito, M.K. What Combination Therapy with a Statin, If Any, Would You Recommend?. Curr Atheroscler Rep 13, 12–22 (2011). https://doi.org/10.1007/s11883-010-0150-3

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